Provider Demographics
NPI:1720225881
Name:MEHTA-PANDYA PROFESSIONAL DENTAL CORP
Entity Type:Organization
Organization Name:MEHTA-PANDYA PROFESSIONAL DENTAL CORP
Other - Org Name:BAYSIDE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYUR
Authorized Official - Middle Name:B
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-792-4627
Mailing Address - Street 1:1884 1/2 S PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-6117
Mailing Address - Country:US
Mailing Address - Phone:310-792-4627
Mailing Address - Fax:310-792-4629
Practice Address - Street 1:1884 1/2 S PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-6117
Practice Address - Country:US
Practice Address - Phone:310-792-4627
Practice Address - Fax:310-792-4629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA504911223G0001X
CA508051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty